Anestis et al. 371 relationshin with suicidal behavior than the abo erlethality The in relationshin be risk factors does not render the relationship between trait siveness of attempt and lethality of attempt has also been replicated in a sample of adolesc ents (Witte et al,2008). tainly calls into que tudies exa ning the ass ation ort th distal variety of samples.more impulsive attempts were associated with lower depre ssion scores (e.g,Brown,Overholse Critical Review of Studies Examining irito,&Frit 19009,si ner et a 2014 Impulsivity of Attempts Kellv Malone, Mann,2000:Suomine In this sectionwe vide a critical review of findings fro Henriksson,Ostamo,&Lonnqvist,1997;Wojnar et al. studics examining the impulsiveness of specific suicide al.,2007an attempts.We opted against using a meta-analysis in this null cause mea the a reno ion of the article was on the mea and o childhood sexual abuse,and Conner et al.(2006)reporte alization of the impulsivity of attempts.In this sense.there that impulsive attempte were less likely to me was no second va ted that this e s note Sher.2008).and a history of childhood sexual abus of impulsivity of attemnts problematic measuremer )re associated with severe suicidal behav approa are evi with the notion ive plan ning attemnts Wher considered within the context o these find out e. ings,models claiming suicidal behavior frequently occurs Study Selection impulsively are particularly problematic,as such perspec large por and fewer risk factors for severe.repeated.and lethal suicida extent to which participants engaged in suicidal behavi behavior. that involved little to no planning.In some studies,the ed the us sure desigr Conceptual Issues With Studies Examining the siven case Impulsiveness of Specific Suicide Attempts distance of attempt from home)or involved one or m Studies that examine impulsiveness of attempts differ in many ways,including the method of measurement and the attempts considered impulsive.Inst Summary of Results of Studies Examining the d ir %(Houston.Hawton.Sheppard.2001)to(Razin Impulsiveness of Specific Suicide Attempts et al.,1991).As such,there does not appear to be a co nsus In studies that examined the impulsivity of specific suicide as to whether impul a rare phe the gene eral tren appears to argue in greater detail below.we believe the actual p uicideemBac-rd olu20) tion of attempts that can accurately be described as impulsive to be at or very close to 0 omihetisirencofahemgtasmeyamciate on s likel ty ny. ed with which an individual must report having thoughts abou at least once Nakagawa and colleagues (2000)found that attempting suicide.In some studies,participants are asked i less planning was associated with lower lethality.In additior they contemplated eir att mpt for longer tha min pric ner and colleagues( of planning were s fromAnestis et al. 371 relationship with suicidal behavior than the above-mentioned risk factors does not render the relationship between trait impulsivity and suicidal behavior meaningless, but it cer￾tainly calls into question its centrality. Indeed, our central thesis is not that trait impulsivity is irrelevant to suicidal behavior but rather that the relationship is indirect and distal. Critical Review of Studies Examining Impulsivity of Attempts In this section, we provide a critical review of findings from studies examining the impulsiveness of specific suicide attempts. We opted against using a meta-analysis in this sec￾tion because such analyses measure the average strength of the relationship between two variables and the focus of this portion of the article was on the measurement and conceptu￾alization of the impulsivity of attempts. In this sense, there was no second variable to which impulsivity of attempts was being compared. As noted earlier in the article, we antici￾pated that this review would yield an inconsistent definition of impulsivity of attempts, problematic measurement approaches, and a pattern of results that does not align well with the notion that suicidal behavior frequently occurs with￾out extensive planning. Study Selection Inclusion criteria for studies examined in our critical review involved reporting of any results intended to measure the extent to which participants engaged in suicidal behavior that involved little to no planning. In some studies, the assessment approach involved the use of a measure designed to assess impulsiveness of attempts. In other cases, this included the interpretation of objective circumstances (e.g., distance of attempt from home) or involved one or more questions from within a broader measure. These criteria yielded 49 studies (see Table 2). Summary of Results of Studies Examining the Impulsiveness of Specific Suicide Attempts In studies that examined the impulsivity of specific suicide attempts, the general trend appears to indicate that attempts that involve less planning are associated with less severe out￾comes. For instance, in a sample of individuals hospitalized for a suicide attempt, Baca-Garcia and colleagues (2001) found that impulsiveness of attempt was inversely associated with lethality of attempt. Similarly, in a sample of adult inpa￾tients diagnosed with depression who had attempted suicide at least once, Nakagawa and colleagues (2009) found that less planning was associated with lower lethality. In addition, in a sample of 673 attempters, Conner and colleagues (2006) found that greater levels of planning were associated with greater lethality. The inverse relationship between impul￾siveness of attempt and lethality of attempt has also been replicated in a sample of adolescents (Witte et al., 2008). Studies examining the association between impulsiveness of attempts and psychopathology also fail to support the view that suicidal behavior is frequently impulsive. Across a variety of samples, more impulsive attempts were associated with lower depression scores (e.g., Brown, Overholser, Spirito, & Fritz, 1991; Conner et al., 2006; Jeon et al., 2010; Nakagawa et al., 2009; Simon et al., 2001; Soloff, Lynch, Kelly, Malone, & Mann, 2000; Suominen, Isometsa, Henriksson, Ostamo, & Lonnqvist, 1997; Wojnar et al., 2009; Wyder & de Leo, 2007; see Conner et al., 2007 and Giegling et al., 2009 for null findings). Similarly, Wojnar et al. (2009) found that impulsive attempters were less likely to report a family history of suicide or having experienced childhood sexual abuse, and Conner et al. (2006) reported that impulsive attempters were less likely to meet diagnostic criteria for substance dependence. Given that depression (e.g., Bostwick & Pankratz, 2000), substance use (Bagge & Sher, 2008), and a history of childhood sexual abuse (e.g., Joiner et al., 2007) are associated with severe suicidal behav￾ior, these findings are evidence that individuals in particu￾larly high-risk groups are less likely to engage in impulsive attempts. When considered within the context of these find￾ings, models claiming suicidal behavior frequently occurs impulsively are particularly problematic, as such perspec￾tives seem to suggest that a large proportion of attempts involve individuals with lower levels of psychopathology and fewer risk factors for severe, repeated, and lethal suicidal behavior. Conceptual Issues With Studies Examining the Impulsiveness of Specific Suicide Attempts Studies that examine impulsiveness of attempts differ in many ways, including the method of measurement and the proportion of attempts considered impulsive. In studies that dichotomized attempts as impulsive or non-impulsive, the proportion of attempts considered impulsive has ranged from 13% (Houston, Hawton, & Sheppard, 2001) to 97% (Razin et al., 1991). As such, there does not appear to be a consensus as to whether impulsive suicidal behavior is a rare phenom￾enon or representative of the vast majority of attempts. As we argue in greater detail below, we believe the actual propor￾tion of attempts that can accurately be described as impulsive to be at or very close to 0%. One explanation for this large discrepancy is likely the inconsistent operationalization of the time frame during which an individual must report having thoughts about attempting suicide. In some studies, participants are asked if they contemplated their attempt for longer than 15 min prior to attempting (e.g., Hawton, Kingsbury, Steinhardt, James, & Fagg, 1999). In others, the time frame ranges from “none; Downloaded from psr.sagepub.com at Remen University of China on September 6, 2015